Remote training and teleproctoring in gastrointestinal endoscopy for practicing surgeon in rural Uganda.

BACKGROUND: There is a significant, unmet need for endoscopy services in rural Uganda. With limited diagnostic and therapeutic interventions, patients in these communities often present with advanced disease. Practicing surgeons must continually adapt to new techniques to meet the needs of their patient populations. Here, we present a remotely proctored endoscopy training program for a surgeon practicing in an area devoid of endoscopic capabilities. METHODS: This was a retrospective case series conducted between February 2020 and December 2022 at Kyabirwa Surgical Center (KSC). After a 1-week in-person training camp, one surgeon performed endoscopy under guidance of a remote proctor. Patient data and outcomes were collected retrospectively. RESULTS: The previously endoscopic naïve practicing Ugandan surgeon was remotely proctored for 139 endoscopic cases and he subsequently independently performed 167 diagnostic colonoscopies and 425 upper endoscopies. Therapeutic endoscopy was conducted under remote guidance after proficiency in diagnostic endoscopy. A total of 43 therapeutic procedures were performed, including 29 esophageal stent placements, 5 variceal bandings, and 9 foreign body retrievals. All procedures were completed without complication. CONCLUSION: Our center developed a remotely proctored endoscopy program that allowed for training of practicing surgeons in an area lacking endoscopic services. Despite its limitations, remotely proctored endoscopy serves as a unique but highly valuable method of expanding access to endoscopy, particularly in areas that lack adequate training opportunities.

Implantable Biologics for Soft Tissue Surgery Reinforcement.

Soft tissue reinforcement focuses on medical grafts that are designed to support and regenerate soft tissue under or near suture lines. Soft tissue is defined as areas of similarly specialized cells that function to connect, support, and surround other structures and organs of the body. These tissues include skin, subcutaneous tissue, fascia, ligaments, tendons, fibrous tissues, fat, synovial membranes, and muscle. Most of the implantable devices used for this purpose are made of collagen, the most abundant protein in mammals and a key component of the extracellular matrix of soft tissues that allows for tissue repair. For suture line reinforcement, exogenous collagen from various sources is implanted under or in continuity with the suture line to allow for increased strength and better healing. First introduced in the field of breast reconstruction, this practice is now also used in hernia repair, dural repair, vaginal slings, amputation reinforcement, tendon repair reinforcement, and even dental soft tissue regeneration.

Skin Expansion Technology in Acute Burns and Chronic Wounds.

The ability to grow skin has long been a topic of study and therapeutic interest. Currently, the main ways of doing this are 1) by placing tissue-expansion devices in the subcutaneous space and expanding skin over time, which can then be moved to cover contiguous structures, and 2) via processes that require relatively long (30 days) incubation periods to grow the patient's autogenous skin into laminar sheets. Over the past five years, there have been significant developments in the ability to expand skin cells, either at the bedside or in the laboratory, but much more rapidly than with previous methods. We explore and discuss the current skin cell-expansion techniques, focusing on point-of-care therapeutic interventions that can be used in the burn population as well as the chronic wound population, hair follicle stem-cell incubation techniques and studies supporting this therapy, as well as micro bullae grafting, and morcellated skin cell therapy. The current data supporting these therapeutic interventions and their current direction are outlined in detail.

Necrotising cellulitis of the breast associated with a fungating mucinous adenocarcinoma.

Breast necrotising soft tissue infections (NSTIs) are rare surgical emergencies with limited cases described in the literature. Here, we discuss a unique case of a woman in her 70s who presented with newly diagnosed diabetes and a neglected right breast cancer associated with breast erythema, skin necrosis, crepitus on examination and breast soft tissue gas seen on CT requiring emergent total mastectomy with partial pectoralis muscle excision. Pathology revealed a 15 cm invasive mucinous adenocarcinoma and necrotising polymicrobial cellulitis with a large abscess cavity. She recovered from her surgery with strict glycaemic control and a 10-day course of antibiotics. Multidisciplinary tumour board recommended adjuvant anastrozole, abemaciclib and postmastectomy radiation to complete her oncological treatment. Although exceedingly rare, it is important that clinicians be aware of, promptly recognise and properly treat NSTIs of the breast, as correct care can be life-saving from both infection and malignancy.

Arterial Leg Ulcers in the Octogenarian.

Arterial leg ulcers are a debilitating sequela of chronic ischemia, and their management, particularly in the octogenarian, is an immense challenge. ALUs are frequently a manifestation of end-stage peripheral arterial disease, and their presence portends a high morbidity and mortality. Management primarily relies on restoration of flow, but in the geriatric population, interventions may carry undue risk and pathologies may not be amenable. Adjunctive therapies that improve quality of life and decrease morbidity and mortality are therefore essential, and understanding their benefits and limitations is crucial in developing a multimodal treatment algorithm of care for the uniquely challenging octogenarian population.

Novel Reconstructive Ladder for Reestablishing Functional Skin Graft Coverage in Chronic Lower Extremity Wounds.

Background: Chronic lower extremity (LE) wounds frequently require significant interventions to close. The success of any method depends on an adequately prepared wound bed, while factors including wound size, perfusion, contamination, or exposed tissue structures can thwart efforts. We propose a standardized algorithm of care utilizing an acellular dermal matrix, split-thickness skin graft (STSG), and negative pressure wound therapy (NPWT) for the treatment of LE wounds. Methods: This was a single-center, retrospective cohort study examining patients who underwent LE wound debridement, placement of fetal bovine dermis (FBD), and STSG between 2016 and 2022. The primary outcome was wound closure, while secondary outcomes were wound infection and amputation-free survival. Results: Twenty patients (mean age 59 years, M:F 12:8)-including 24 LE venous ulcers (29.4%), amputation sites (29.4%), diabetic foot ulcers (25.0%), and atypical wounds (16.7%) with an average area of 39.15 cm2-underwent debridement and FBD placement followed by STSG a median of 61 days thereafter. Of these patients, 83.3% received NPWT after FBD and STSG with 86% closure. There was successful engraftment in 92% of wounds whose FBD placement was within 2 months of STSG. Of wounds that had <50% engraftment, 75% had a STSG placed over 2 months after FBD placement. Of those patients with post-STSG infection, 75% had the graft placed >2 months after FBD placement, one of which required proximal amputation. Conclusions: By following a treatment plan including debridement with treatment of infection, application of FBD with placement of STSG within 2 months thereafter, and reinforcing NPWT, chronic wounds will have an increased rate of successful reepithelialization. Many cases experienced delays from FBD engraftment until STSG application due to schedule and insurance impediments, which led to less favorable outcomes. Therefore, a protocol that involves scheduling the placement of STSG 4 weeks after successful engraftment of FBD has been adopted.

Low risk is low risk, regardless of race or ethnicity: Outcomes of prostate cancer active surveillance and factors associated with reclassification in a racially diverse cohort.

INTRODUCTION: Active surveillance (AS) is the standard for very low- and low-risk prostate cancer. Although risk factors for pathologic reclassification while on AS have been identified, results are mixed for non-Hispanic Black (NHB) and Hispanic ethnicity. We aim to further explore how race and ethnicity may be affecting AS participation and outcomes in a primarily urban, diverse, and vulnerable population. MATERIALS AND METHODS: Patients eligible for AS from 2005-2020 were reviewed. Demographics, race/ethnicity, prostate specific antigen (PSA), prostate volume, and pathologic characteristics were analyzed between patients enrolled in AS and those that underwent immediate therapy. Kaplan-Meier survival analysis was used to compare biochemical recurrence (BCR) rates. Cox proportional hazards models were used to develop prediction models for clinical reclassification. RESULTS: A total of 471 men were eligible for AS. Of those, 188 (39.9%) enrolled in AS while 283 (60.1%) underwent immediate radical therapy. No significant differences were found in racial/ethnic composition between the AS and immediate treatment groups. In our AS cohort, 79 (42.0%) experienced clinical reclassification and underwent deferred treatment. BCR rates were similar between treatment groups. Race/ethnicity were not found to be predictors of clinical reclassification, while metrics at diagnostic biopsy such as elevated PSA, higher PSA density, and lower prostate volume increased reclassification odds. CONCLUSIONS: In our diverse population, NHB race and Hispanic ethnicity were not significant predictors of adverse reclassification while on AS. Our findings support utilizing other metrics taken at initial biopsy to identify high-risk patients such as PSA, prostate volume, and PSA density.

Mark M. Ravitch: A Staple in Surgical History and Innovation.

Mark M. Ravitch is a surgeon worth acknowledging. He is credited for revolutionizing pediatric surgery as a subspecialty, mastering chest wall deformities and introducing the surgical stapler to the United States, to name a few. Above all, he was a notable leader, teacher, and author. This historical vingette is a brief snapshot of his biography and various achievements.

Paraurethral Leiomyoma as an Incidental Finding in Patient with Fibroid Uterus.

Paraurethral leiomyomas are rare benign fibromuscular tumors developing from urethra. The presenting symptoms are usually related to mass effect. We present a case of an incidental diagnosis of a paraurethral leiomyoma in a patient with a fibroid uterus. Case was managed by hysterectomy concurrent with periurethral leiomyoma excision. Patient had uncomplicated clinical course. Due to close localization of paraurethral leiomyoma to urethra and bladder care must be taken to minimize the injury during resection.